Citation Nr: 9906443
Decision Date: 03/09/99 Archive Date: 03/18/99
DOCKET NO. 92-01 361 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in San Diego,
California
THE ISSUES
1. Entitlement to service connection for a left shoulder
disability.
2. Entitlement to service connection for a left elbow
disability.
3. Entitlement to service connection for a right elbow
disability.
4. Entitlement to service connection for a thoracic spine
disability.
5. Entitlement to service connection for thoracic outlet
syndrome.
REPRESENTATION
Appellant represented by: Disabled American Veterans
WITNESS AT HEARING ON APPEAL
The veteran
ATTORNEY FOR THE BOARD
J.R. Bryant, Associate Counsel
INTRODUCTION
The veteran served on active duty from April 1961 to April
1981.
This matter comes before the Board of Veterans' Appeals
(Board) on appeal from a September 1989 rating determination
by the Anchorage, Alaska, Regional Office (RO) of the
Department of Veterans Affairs (VA). Subsequent to this
rating decision, the veteran relocated to California, and his
claims are now administered by the RO in San Diego. In
current status the case returns to the Board following the
completion of development made pursuant to its August 1992
and September 1994 remands.
FINDINGS OF FACT
1. All available, relevant evidence necessary for an
equitable disposition of the appeal has been obtained.
2. The veteran's left shoulder, bilateral elbow and thoracic
spine symptoms in service were acute and transitory and
chronic disabilities were not then present.
3. The veteran has not presented competent medical evidence
of a relationship between service and his current left
shoulder, bilateral elbow and thoracic spine disabilities.
CONCLUSION OF LAW
Left shoulder, bilateral elbow and thoracic spine
disabilities and thoracic spine outlet syndrome were not
incurred in or aggravated by service, nor may they be
presumed to have been incurred therein. 38 U.S.C.A. §§ 1110,
1112, 1113, 1131, 1137, 5107(a), 7104 (West 1991 & Supp.
1998); 38 C.F.R. §§ 3.303(b), 3.307, 3.309 (1998).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
Factual Background
Service medical records show that in March 1963 the veteran
was treated for complaints of pain in the mid-back following
horseback riding. In June 1973, he was treated for injuries,
including left elbow pain, following a motorcycle accident.
An examination revealed no significant weakness, sensory
loss, atrophy or numbness in the arm and no involvement of
the hands or fingers. Reflexes were active and symmetrical
and there was no evidence of root compression or other
specific neurological involvement. A month later, the
veteran was evaluated for continued left elbow pain. There
was no limitation of motion, but the elbow felt tight with a
pulling effect on bending, and there appeared to be fluid in
the area. There was pain with extreme flexion and extension.
Motor and sensation were intact. The clinical impression was
minimal olecranon bursitis of the left elbow.
In March 1978, the veteran was treated for body aches and
joint pain. Specifically, he complained of right elbow pain
with certain gripping and lifting maneuvers. The clinical
impression was tennis elbow of the right arm. In December
1978, he was treated for complaints of myalgia and aching
associated with a viral syndrome. In August 1979, he was
evaluated for complaints of intermittent joint aches of the
shoulder and elbows. The clinical assessment was arthralgia
of questionable etiology. In August 1980, he was evaluated
for tenderness of both elbows. In November 1980, he was
evaluated for pain and tenderness of the left lateral elbow.
There was tenderness to palpation and increased pain with
forced supination. The clinical assessment was bursitis,
tennis elbow. The service medical records are otherwise
negative for complaints associated with thoracic spine outlet
or thoracic spine disability. The veteran's examination
report at retirement in 1980 was negative for any complaints
or findings of chronic residual disability.
Post-service VA treatment records show that the veteran was
treated in October 1982 for bilateral shoulder pain and
thoracic pain on deep respiration secondary to viral illness.
In May 1985, he was seen for complaints of bilateral shoulder
pain, diagnosed as bursitis. In August 1985, he was
evaluated for complaints associated with his elbows and
shoulders. The clinical assessment was degenerative joint
disease. In March 1986, the veteran was evaluated for right
upper back and medial upper scapula pain secondary to heavy
lifting at work. There was tenderness at the right T4, T5,
T6 and T7 areas and in the area of the paravertebral muscle.
The clinical assessment was right mid thoracic strain versus
radicular neck symptoms. The veteran was evaluated in March
1988 for right elbow pain diagnosed as lateral epicondylitis.
In December 1988, the veteran was evaluated for chronic
recurrent mid and upper back pain. He gave a history of
upper thoracic spine and neck pain for more than eight years.
X-rays of the thoracic spine showed minimal marginal
hypertrophy changes with narrowed T8-T9 vertebrae. The
clinical impression was chronic thoracic spine pain.
At a VA examination in April 1989, the veteran reported that
he injured his back and neck on two different occasions while
in service. The orthopedic examination showed that the
entire spine moved well except for the cervical spine. There
were full ranges of motion of all of the joints of the upper
extremities but with pain, particularly on the extremes of
shoulder motion. There was no evidence of swelling or
deformity. There was tenderness in the region of the
bicipital groove of the humerus bilaterally and over the
lateral epicondyle of the elbow bilaterally. X-rays from
Bassett Army Community Hospital were reviewed and revealed
mild arthritic changes of the cervical, dorsal and lumbar
spines. The pertinent diagnoses were mild to moderate
degenerative changes in the dorsal spine, possible thoracic
outlet syndrome, bilateral tendonitis of the shoulder and
epicondylitis of the elbow, bilaterally. The examiner opined
that some of the veteran's back symptoms could be explained
on the basis of chronic myofascitis.
In a September 1989 rating decision, service connection was
denied for bilateral elbow and thoracic disabilities on the
basis that the conditions noted in service were acute and
transitory and did not become chronic until several years
after separation from service. Furthermore the current left
shoulder, bilateral elbow and chronic thoracic spine
disabilities and thoracic outlet syndrome were not noted in
service.
The veteran presented testimony at a RO hearing in December
1991 about the onset and severity of his claimed
disabilities. He testified that he hurt his back on two
separate occasions during service and that his main problem
was low back pain. He testified that he could not accurately
tell when his shoulder and elbow pains began but was
originally told that he had tennis elbow or bursitis. He
testified that, in 1983, he was working in construction and
found that he could no longer swing a hammer. He stated that
he was told that his problem was due to his service-connected
cervical spine disability.
In August 1992, the Board remanded the case for an
examination to determine whether degenerative changes in the
thoracic spine may be disassociated medically from the
degenerative disease in the cervical and lumbar areas and to
determine the etiology of thoracic outlet syndrome and
whether it may be related to the service-connected
degenerative disease of the spine.
At a VA examination in October 1992, the veteran gave a
history of several episodes of injury in service, the first
in 1968. He reported that, at that time, he had pain in
several areas which resolved over several weeks without
medical treatment. He later sustained injuries in a
motorcycle accident in 1973 and subsequently had progression
of diffuse aches and pains. Over the previous seven years,
the veteran had noted the progressive onset of bilateral
shoulder pain, increased with overhead activity. He also
noted intermittent elbow pain with increase in his symptoms
in the forearm and elbow with exertion. The veteran's most
notable symptoms were with overhead activity resulting in
pain and numbness in both upper extremities. He denied any
history of significant trauma or musculoskeletal injury.
Shoulder range of motion was reported as 130 degrees of
flexion, 70 degrees of internal rotation and 30 degrees of
external rotation. The veteran had negative impingement
sign, negative apprehension sign and a negative two-finger
supraspinatus test. He had no significant tenderness of the
acromioclavicular joint or biceps tendonitis. He had
positive Rous, Spurling and modified Adson's tests.
Examination of the elbows revealed full extension, 140
degrees of flexion bilaterally and 80 degrees of pronation
and supination of both upper extremities. He had a positive
Tinel's at the right elbow and negative Tinel's at the left
elbow. Phalen's examination was negative bilaterally.
Examination of the back revealed normal contours and no
significant point tenderness. There was no deformity of the
thoracolumbar spine. The veteran could flex to 75 degrees
without difficulty and could extend to 10 degrees. Right and
left lateral bending were both to 10 degrees. Sensory
examination was remarkable for sharp and dull discrimination
intact to both upper and lower extremities with no evidence
of thenar or ulnar innervated atrophy. The clinical
impression was mild traumatic arthritis of both shoulders and
thoracic outlet syndrome of the shoulders, bilaterally.
There was no diagnosis pertaining to either elbow.
VA treatment records show that the veteran was evaluated
between September 1990 and September 1991 for continued
bilateral shoulder pain and left elbow pain. In October
1990, he was treated for symptoms diagnosed as shoulder
impingement syndrome.
At a VA examination in May 1993, the veteran complained of
pain over the bilateral posterior elbows with the right side
greater than left. He described the pain as a constant
baseline aching which was tolerable, but he noted that the
pain worsened with activity such as lifting, pulling, pushing
or overhead-type activities. He noted occasional cramping in
the fingers when grasping for a prolonged period. He denied
dropping objects but noted occasional radiation of pain from
the elbow to the ulnar aspect of both hands. The examination
revealed no evidence of shoulder girdle atrophy and no
significant increased upper extremity pain or radiculopathy
with range of motion of the neck. There was a positive
Spurling's test on the left supraclavicular area. The
veteran had a negative Bruce, Adson's and reverse Adson's
tests. Evaluation of the upper extremities revealed full
range of motion of the left shoulder and increased pain with
abduction and elevation of both shoulders, right greater than
left. There was no evidence of swelling, erythema, or warmth
and no tenderness along the glenohumeral or acromioclavicular
joint areas. There was also no tenderness along the
posterior aspect of the glenohumeral joint as well. The
veteran has negative apprehension test and no evidence of
rotator cuff tear. Deltoid strength was 5/5 and biceps,
triceps and motor strength were 5/5. The veteran had
posterior elbow pain with resistance to elbow extension.
Range of motion of the elbow was from 0 to 140 degrees. The
veteran has no increased radiation of pain along both upper
extremities and numbness with forward flexion of the elbow.
Evaluation of the elbows revealed no swelling, erythema or
warmth. The veteran had full range of motion of the wrists
and positive Tinel's over the "palpebral tunnel area" with
radiating pain along the ulnar nerve distribution distally.
The ulnar nerve was not flexible and the symptoms did not
increase with extremes of flexion of the elbow. There was
full supination and pronation of the forearm and no evidence
of instability. There was no evidence of thenar or
hypothenar atrophy or intrinsic atrophy. The veteran was
able to make a full fist, touching the tips of the fingers to
the proximal palmar crease and was able to touch the tips of
the digits with his thumb. There was normal grip strength
bilaterally and no evidence of intrinsic lesion. There was
normal sensation with the exception of an increase two-point
discrimination at the ulnar side of the left ring finger and
the right finger as well. Grip strength appeared to be equal
bilaterally and deep tendon strength was also normal
bilaterally. Distal radial pulses were intact as well. The
clinical assessment was possible "palpebral tunnel
syndrome" of bilateral elbows, right greater than left.
The examiner concluded that it was unlikely that the
veteran's previous diagnosis of thoracic outlet syndrome was
caused by degenerative disease of the cervical spine since
there was no evidence of significant radiculopathy with range
of motion of the cervical spine. The veteran had positive
Tinel's test over the "palpebral tunnel" and carpal tunnel
areas suggesting a possible entrapment syndrome over the
cubital tunnel and possibly the carpal tunnel area. The
motor examination was unremarkable throughout both upper
extremities with some sensory changes on the ring finger of
both hands.
Electromyographic and nerve conduction studies performed in
June 1993 showed normal studies of both upper limbs with no
evidence to suggest carpal tunnel syndrome, ulnar motor or
sensory neuropathy, radiculopathy (C5 through T1 myotomes
tested bilaterally), plexopathy or other neurogenic lesion in
either upper limb.
The Board remanded the case in September 1994 for further
development and for compliance with its 1992 remand.
At a VA examination in December 1994, X-rays of the thoracic
spine showed minimal narrowing of the disc space at T8-9
associated with minimal spondylosis. X-rays of the left
shoulder and left elbow were within normal limits.
The veteran was then scheduled for examination by a
rheumatologist in accordance with the September 1994 remand
instructions. At that examination, ultrasound of the
carotid/subclavian arteries revealed no significant stenotic
lesions and the carotid systems showed no evidence of flow
limitation. The right upper extremity blood pressure was
140/98 and the left upper extremity was 150/100. There was
no evidence of significant stenotic lesion identified at both
subclavian arteries and both carotid systems. The veteran
complained of neck, arm and shoulder pain with tingling
sensation and numbness in the fingers of both hands, worse on
the right. His symptoms occurred intermittently and were not
present at the time of the examination. Range of motion of
the shoulders was full and there was no tenderness or
synovitis. Range of motion of the elbows was also full with
no evidence of synovitis. The hands had full range of motion
with no deformities or synovitis. The veteran had normal
peripheral pulses and positive Heberdeen's nodes. Sensation
was normal in both hands and Tinel's sign was negative. The
rheumatologist concluded that based on the physical
examination and ultrasound of the carotid/subclavian
arteries, the veteran had no evidence of thoracic outlet
syndrome.
The examination was considered inadequate and was returned
for compliance with the previous 1994 Remand.
The veteran was subsequently examined by VA in February 1996.
His history of longstanding bilateral elbow and left shoulder
pain was noted. Examination of the left shoulder was
negative for swelling or deformity. He had significant left
shoulder pain and decreased range of motion without evidence
of crepitus or loose bodies. Flexion of the left shoulder
was to 100 degrees, extension to 40 degrees and abduction to
90 degrees. Internal rotation was to the lumbar spine and
external rotation was to 30 degrees. Palpation over the
shoulder elicited several areas that were remarkably tender,
consistent with trigger points. X-rays from 1996 were noted
to show no significant bony abnormality and no evidence of
lytic lesions or tumorous processes. The glenohumeral joint
space was well maintained. There was no significant
osteophytic degeneration. The diagnosis was intermittent,
chronic left shoulder pain probably secondary to fibromyalgia
versus rotator cuff tendonitis.
Examination of the elbows revealed no evidence of swelling,
deformity, instability, tenderness, effusion or crepitus.
Range of motion of the right elbow was flexion to 90 degrees,
extension to 60 degrees, pronation and supination to 80
degrees. Range of motion of the left elbow was flexion to 60
degrees, extension to 90 degrees and pronation and supination
both to 80 degrees. X-rays studies were essentially normal.
The diagnoses were intermittent right and left elbow pain
currently not present, but possibly secondary to early
degenerative arthritis not seen on X-rays versus
fibromyalgia-type pain. The examiner stated that the veteran
had been exceptionally uncooperative and unable to give an
accurate historical record as to the onset of the pain which
was unclear from an extensive review of the claims file. The
examiner concluded that it was impossible to determine the
etiology of each of these disabilities. Because the veteran,
however, did not appear to have a constellation of symptoms
of thoracic outlet syndrome, the examiner indicated that the
symptoms were independent processes and not attributable to
thoracic outlet syndrome.
The veteran attributed his complaints of spinal pain to
injuries sustained in service, but he was unwilling to give
specific details about the accidents. Examination of the
spine revealed no clinical findings of postural abnormalities
or fixed deformity. Range of motion of the thoracolumbar
spine was forward flexion to the mid-tibia, backward
extension to 15 degrees, left and right lateral flexion to 15
degrees and right and left rotation to 90 degrees. The
veteran complained of pain on motion. There was normal
sensation from L4-S1 dermatomes and normal light touch
sensation throughout both upper extremities. There was 5/5
muscle strength in both upper extremities and some discomfort
with forcible contractions. The veteran had excellent
dexterity in both hands, but he complained of some tingling,
numbness and pain. There was negative Spurling's, Adson's
and modified Adson's tests. X-rays of the thoracolumbar
spine were essentially negative except for very mild
spondylosis. The diagnoses were those of multiple focal
areas of myofascial pain probably secondary to a combination
of fibromyalgia and mild multi-level thoracolumbar
spondylosis (degenerative arthritis). There was no evidence
of thoracic outlet syndrome.
The examiner opined that thoracic outlet syndrome is at best
a diagnosis of exclusion and that the veteran's complaints
and constellation of symptoms did not correspond to the
entity of thoracic outlet syndrome. Although it was possible
to rule this out, the fact that the veteran had a normal EMG,
normal carotid ultrasound, negative tests results and did not
have a clinical constellation of complaints and symptoms
representing thoracic outlet syndrome, it was the examiner's
opinion that the veteran did not have thoracic outlet
syndrome and that another explanation was responsible for the
veteran's pain.
In a letter dated in December 1997 the veteran's
representative expressed dissatisfaction with the examination
and requested an additional evaluation.
At an orthopedic examination in December 1997, the veteran's
right elbow had a good range of motion with 0 degrees of
extension and 120 degrees of flexion. There was tenderness
over the lateral epicondyle and pain with forced flexion of
the wrist or pronation of the wrist. There was medial
epicondyle tenderness of the left elbow and pain with forced
extension and supination of the wrist. The left shoulder had
full range of motion with abduction to 180 degrees, forward
flexion to 90 degrees, extension to 60 degrees, external and
internal rotation to 80 degrees. There was slight sub-
acromial tenderness on palpation and slight tenderness over
the acromioclavicular joint. There was a negative Spurling,
Adson's and Harkin's signs. There was no evidence of
impingement and the veteran had normal rotator cuff
musculature and motor function at 5/5 and symmetric. X-rays
showed significant acromioclavicular spurring as well as some
mid joint narrowing. Otherwise, there was normal examination
of his shoulder. Studies of the elbows were within normal
limits with no degenerative changes noted.
The clinical assessment was acromioclavicular degenerative
joint disease, right elbow lateral epicondylitis and left
elbow medial epicondylitis. The examiner stated that the
veteran's left shoulder condition was a real and painful
condition and that the bilateral epicondylitis was usually
secondary to repetitive trauma or activity. Furthermore, it
was reportedly difficult to assess whether any of the three
conditions were secondary to the veteran's injuries in the
military. Although the veteran's epicondylitis was deemed to
be likely due to repetitive trauma at his present employment,
the examiner noted that it possibly started during his
military involvement.
In a June 1998 Report of Contact, it was noted that an
examination had been requested to resolve additional issues
raised by the veteran's representative. The veteran
indicated that he was weary of the appeal's process and
numerous examinations and that he did not want to submit to
any more examinations. In a subsequent Report of Contact in
October 1998 the veteran again stated that he felt that he
had been asked to report for unnecessary VA examinations and
refused to report for any more.
Analysis
The veteran's claims are well grounded within the meaning of
38 U.S.C.A. § 5107(a). That is, he has presented plausible
claims. Service medical records, VA medical records, hearing
testimony and statements from the veteran were associated
with the claim. To the extent that additional testing is
desirable and could be probative of the veteran's claim, the
Board notes that he has refused to cooperate and submit to
additional examination. The Board therefore finds that
remand to again request such testing would be futile.
Based on the specific circumstances of this case, the Board
thus finds that all available, relevant evidence necessary
for an equitable disposition of the appeal has been obtained,
and that no further assistance is required to comply with the
duty to assist mandated by 38 U.S.C.A. § 5107.
The law permits the granting of service connection for a
disability which results from disease or injury incurred in
or aggravated by active military service. 38 U.S.C.A.
§§ 1110, 1131. Service connection may also be granted on a
presumptive basis for certain chronic diseases, including
arthritis, if manifest to a degree of 10 percent or more
within a year after service discharge. 38 U.S.C.A. §§ 1101,
1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Regulations
also provide that service connection may be granted for any
disease diagnosed after discharge, when all the evidence,
including that pertinent to service, establishes that the
disease was incurred in service. 38 C.F.R. § 3.303(d).
Service medical records show that the veteran was evaluated
for intermittent joint pain involving both shoulders, a left
elbow injury following a motorcycle accident, right elbow
pain, diagnosed as tennis elbow, and mid-back pain. With
respect to the left shoulder, right elbow and mid-back pain,
the episodes were apparently acute and transitory in nature
and resolved with treatment, as there are no subsequently
dated medical records on file reflecting further evaluation
and treatment during the remaining months of service.
Indeed, his November 1980 retirement examination revealed a
normal spine and upper extremities, with the exception of a
mass lesion of the right upper lateral arm.
There is no credible evidence concerning whether the in-
service complaints and injuries resulted in chronic residuals
or whether there has been continuing symptomatology since
then. Also no competent medical evidence has been presented
to show a nexus or connection between any current left
shoulder, bilateral elbow or thoracic spine disabilities and
his period of service. The evidence of record does not
indicate that any disability now present had its origins
during service.
With respect to thoracic spine outlet syndrome, the evidence
of record does not show treatment for such symptoms during
his period of service. The first clinical reference to
thoracic outlet syndrome was in an April 1989 VA examination
report wherein the veteran complained of shoulder pain. At
the VA examinations, however, conducted in December 1994 and
February 1996, the examiner specifically reported that there
was no evidence of the disability.
In December 1994, the examiner noted that the veteran
complained of tingling and numbness in the fingers of both
hands. However an ultrasound of the carotid and subclavian
arteries was negative and thoracic spine outlet syndrome was
not confirmed by EMG and nerve conduction studies. The
February 1996 VA examiner concluded that the veteran's
complaints and constellation of symptoms were not consistent
with thoracic outlet syndrome. The Board finds that the
reports from the VA physicians in December 1994 and February
1996 are particularly probative in refuting the notion that
the veteran has thoracic outlet syndrome.
The Board finds that left shoulder, right and left elbow
disabilities, thoracic spine disability and thoracic outlet
syndrome were not shown in service and that the veteran's
current findings pertaining to these claimed disabilities
have not been medically associated with military service.
The only medical evidence suggesting a connection between any
of the disabilities and service is the December 1997
examiner's statement that it was possible that the veteran's
epicondylitis may have started in service. The examiner
stated, however, that the epicondylitis was likely due to
repetitive trauma at his current employment. Thus, there is
no basis in the current record upon which to grant service
connection for such disorders. In making its determination,
the Board has considered all of the evidence of record, to
include the veteran's hearing testimony, which is credible
insofar as he described his current symptoms and beliefs that
his disabilities are related to military service. He is not
competent, however, to offer a medical diagnosis or medical
opinion regarding etiology. See Espiritu v. Derwinski, 2
Vet. App. 492 (1992).
Under the circumstances, the veteran's refusal to cooperate
in the development of his claims effectively precluded
further development and review of this case. The evidence of
record including VA examination reports do not establish that
the veteran had a service-related left shoulder, bilateral
elbow, or thoracic spine disability or thoracic outlet
syndrome.
Accordingly, the Board concludes that the preponderance of
the evidence is against the claims for service connection and
the appeal is denied.
ORDER
Service connection for left shoulder disability is denied.
Service connection for a right elbow disability is denied.
Service connection for a left elbow disability is denied.
Service connection for a thoracic spine disability is denied.
Service connection for thoracic spine outlet syndrome is
denied.
JAMES L. MARCH
Acting Member, Board of Veterans' Appeals
Department of Veterans Affairs